Application for Private Sewege Disposal System 1967 a Installation HEALTH DEPARTMENT Date 6ne Z /967
ain ersterNq MA 6 S•
APPLICATION TO INSTAL.OR REPAIR
1, PRIVATE SEWAGE DISPOSAL SYSTEM
ne°are? .IYaiieotx/ imaml%9(Sr J3 '7 Crfiaa aPhoae £?7 Sea 3
(Nest be filed is) (Mailing adores) o
N •/ It Address H Of Phone `v
at (Meiling address)
trot [/X Awes Are _sad.•..200AZ moor gn E• oeva.ennne RE 37.95/
Mailing address)
LI/pSneinfrProw Rom"
(Subdivision,Street or Roes Warns or Number,50010 1I,Lot No.)
n of
one th- 0,6
to It®tall
❑ Repair
wage Disposal System e Tank
s
gle Dwelling Unit
C TANK SYSTEM
DISPOSAL OF:
ditional
Quarters
Multiple Dwelling Unit
[ 'Ordinary Household
Sewage and Wastes
Total No, Estimated or Actual
Bed R 33 Water Comsumpti n-"•0 0 Gdy
[kIn Addition Wastes from ❑ Garbage
Automatic Washing Machine Disposal Device
❑ Other
f Material
nk:
DETAILS OF SEPTIC TANK SYSTEM
Rt.gncrete ❑ Other
Depth
Ft. Capacity 900
Depth of 3
Ditches
3 Ft Ditcher 6
��// Surface Drainage
Water Table New 6 Ft Required /44/42°.
/O Ft. Wide.�—.Ft. Dep '¢
Exact.Length Width of
Ditch
z M Each Ditch ✓�� Ft.Di
Tank: Length
face No.of
age Field: Di
of Filter Material
Base to(lover TYl //e a Inches.
Soil S
ation Teats Required
Test Holes
Z
Depth of
Gallons
Inches
Linear
Ft.
Percolation Rate Per Inch t M in 2e .S •C
Hole No. M' .3 Ser 2a
Hole No. Min. Sec.
Hole No Min. Sea
Signed:
gh Sketch of Premises Showing Location of Buildings.Water Supply S.
SEE
tem.Sewage Disposal System,and other Pertinent Details
p L o T' j'L Am i} T TA cY/E D
Ft
b ❑ Approved
rt°roC ❑ Rejected
Signed
THIS APPLICATION MUST BE SUBMITTED IN TRIPLICATE
S-3
a - -
Installation
ifs
HEALTH wnRT
fyon rMB� MASS S.
APPL[GAGON.TO INSTALL OR:REPAIR
PRIVATE SEWAGE,DISPOSAL SYSTEM
Dater R Z /967
(Msitb
none Xi 7- 4e6.Ye
p
dress .. Phone
Or
manias addr®T
or e e_fit,arr S /n/C _Aetna.2a344 -Mew w Sr, te S.in as Plww
WFCrF14.7P,VW RDA°
tSzbditiNOa,street or Red Nema a Number.Seethe.Lot
PS RIP c,6
.a glnebll 0 Repair
RE 3785/
name Disposal System:
le Dwelling Unit ❑ Multiple Dwelling Unit
TANK SYSTEM
SPOSAL OF:
Itional
Zuartars
[j]rOrdinaryHousehold
Sewage and Wastes
Total No Estimated or Actual Ciel.
Bed R 2 Water C r umptic^
(�In Addition Wastes from ❑,Garbage
Automatic Washing Machine DlspoaalDevice
Q Other
Material
k:
DETAILS OF SEPTIC TANK SYSTEM
Erouerete
rank: 4oet /0 ph width
ace No.of Exact Length
;e Field: Ditehei__ ,S—�0f Each Di
d Filter Material
ase to Cover Tih Al A 42 hmhd:
0 Other
4 FL DeptIL--t iFt. Capacity 900 Gallons
Width of Depth ot
Mt. are Ft.Dmh 4 Ft.Ditcher. 36'- Inrhm
Depth of Surface Drainage Linear
r Boil Sggd
Hon TestiRequired:el
Test Holes
II Sketch of Premises Showing
Water Ta..lada 6 Pt Redarge
Pereolahim Rate Per lnrtt
Zen SEC,
Hole N6 Alin.
3 20
Hole No.----Min.
Hole No. Min.
: ..:Signed:
of Buildings.Water Supply Syatem;SewageDispml System.another Pertinent Details
pier paAN gTrfjcf/ED
h
!talent
p Approved
❑ Rejected
Si
THIS APPLICATION MUST BE SUBMITTED IN TRIPLICATE
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